Temporal trend and potential impact of angiotensin receptor neprilysin inhibitors on transcatheter edge-to-edge mitral valve repair.

INTRODUCTION AND OBJECTIVES: Transcatheter edge-to-edge repair (TEER) should be considered in patients with heart failure and secondary mitral regurgitation (MR). Angiotensin receptor-neprilysin inhibitors (ARNIs) have been demonstrated to improve prognosis in heart failure. We aimed to evaluate the impact ARNIs on patient selection and outcomes. METHODS: The population of the Spanish TEER prospective registry (March 2012 to January 2021) was divided into 2 groups: a) TEER before the ARNI era (n=450) and b) TEER after the recommendation of ARNIs by European Guidelines (n=639), with further analysis according to intake (n=52) or not (n=587) of ARNIs. RESULTS: A total of 1089 consecutive patients underwent TEER for secondary MR. In the ARNI era, there was a reduction in left ventricle dilation (82mL vs 100mL, P=.025), and better function (35% vs 38%, P=.011). At 2 years of follow-up, mortality (10.6% vs 17.3%, P <.001) and heart failure readmissions (16.6% vs 27.8%, P <.001) were lower in the ARNI era, but not recurrent MR. In the ARNI era, 1- and 2-year mortality were similar irrespective of ARNI intake but patients on ARNIs had a lower risk of readmission+mortality at 2 years (OR, 0.369; 95%CI, 0.137-0.992; P=.048), better NYHA class, and lower recurrence of MR III-IV (1.9% vs 14.3%, P=.011). CONCLUSIONS: Better patient selection for TEER has been achieved in the last few years with a parallel improvement in outcomes. The use of ARNIs was associated with a significant reduction in overall events, better NYHA class, and lower MR recurrence.

Diagnostic accuracy of regadenoson stress echocardiography: concordance with gated-spect myocardial perfusion imaging.

Regadenoson Stress Echocardiography (RSE) can detect myocardial ischemia, and its diagnostic accuracy should be evaluated. We sought to investigate the agreement between RSE and gated-SPECT myocardial perfusion imaging (MPI) and appraise its diagnostic accuracy. Consecutive patients (n = 202) referred for non-invasive evaluation of myocardial ischemia, with (38.6%) or without a previous coronary artery disease (CAD) diagnosis, were enrolled. Both tests were performed simultaneously. Invasive coronary angiography (CA) is considered the gold standard. The mean age was 70.9 (9.8) years, and 59.9% were male. The prevalence of cardiovascular risk factors (arterial hypertension [81.7%], diabetes mellitus [37.6%], hypercholesterolemia [71.8%], and smoking [18.8%]) was high. Forty-four patients (21.8%) had a non-interpretable electrocardiogram, 15 (34.1%) of them were a result of ventricular paced-rhythm, while 29 (65.9%) were a result of advanced left ventricular branch block. The overall agreement between both diagnostic techniques was good: Gwet's AC1 0.66 (CI95% 0.55 to 0.76), and it was higher in patients without a previous CAD diagnosis: 0.76 (CI95% 0.65 to 0.87). In the biased sample (those who underwent CA), RSE and nuclear study sensitivity was 0.50 and 0.78 and specificity was 0.75 and 0.75, respectively. We noted a dramatic reduction in sensitivity for RSE after debiasing (debiased sensitivity of 0.16), and the negative predictive value was similar to the biased and debiased samples. RSE is in strong agreement with gated-SPECT MPI. However, its low sensitivity and negative predictive value preclude its use as a bedside test to detect myocardial ischemia.

Percutaneous Mitral Valve Repair Vs. Stand-Alone Medical Therapy in Patients with Functional Mitral Regurgitation and Heart Failure.

BACKGROUND: Functional mitral regurgitation (FMR) is a common finding among patients with heart failure (HF) and it is related to adverse events. Outcomes in patients undergoing transcatheter mitral valve repair (TMVR) are still a matter of debate. We performed a meta-analysis to assess mid- and long-term outcomes of patients with FMR treated with MitraClip® compared to medical management. METHODS: We conducted an electronic database search of all published data PubMed Central, Embase, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and Google Scholar databases. The primary end-point was all-cause mortality. The secondary end-points were hospitalizations for HF, need for heart transplantation or left ventricular assist device, unplanned mitral valve surgery, myocardial infarction and stroke. RESULTS: Five studies (n = 1513 patients) were included in the analysis. The summary estimate including all the available studies showed a statistically significant reduction in all-cause mortality favoring MitraClip® (HR 0.56, CI 95% [0.38-0.84]) and HF hospitalizations (HR 0.65; CI 95% [0.46-0.92]). A significant reduction in the indication for advanced HF therapies (OR 0.48; CI 95% [0.25-0.90]) or the need for unplanned mitral valve surgery (OR 0.20; CI 95% [0.07-0.57]) was also found in the group of patients that underwent TMVR. No differences in the incidence of myocardial infarction or stroke were found between both groups of treatment. No publication bias was detected. CONCLUSION: TMVR with MitraClip® system was related to a significant reduction in all-cause mortality, hospitalizations for HF and the need for HF transplant, left ventricular assist device or unplanned surgery beyond 1-year follow up.

Previously diagnosed cancer and mortality after ST-segment elevation acute myocardial infarction treated with primary angioplasty.

OBJECTIVE: We investigated if a previous cancer diagnosis influences the outcome of patients with STEMI treated with primary coronary intervention (PCI). BACKGROUND: ST-segment myocardial infarction (STEMI) and a history of cancer can coexist because both have a high incidence and prevalence. METHODS: Prospective cohort observational study, The primary end-point was total mortality. RESULTS: We included 917 patients, 53 of them (5.8%) were cancer survivors. During follow-up (median, 643 days [interquartile range, 258 to 1,015 days]), 100 patients died, 88 (10.2%) patients without a cancer diagnosis and 12 (22.6%) patients with a previous cancer diagnosis, which was significantly different (log-rank test = 8.4, p = .004). Cancer patients were older (73.4 (11.5) vs. 65.2 (13.8) years, p < .001), with a lower prevalence of previous stroke (1.1% vs. 2.2%, p = .002). Their hemoglobin concentration was also lower (13.4 (2.1) vs. 14.4 (1.7) g/L, p = .001). A trend towards a lower use of coronary stents in cancer survivors was noted (p = .061). Cancer was associated with a high probability of death (HR = 2.37, 95% confidence interval [CI] 1.30-4.34, p = .005). When confounding variables were included, this association was no longer significant (HR = 1.63, 95% CI 0.84-3.18, p = .150). CONCLUSIONS: Patients with a previous cancer diagnosis who had an acute STEMI treated by primary PCI did not seem to have a worse prognosis. The difference in the crude mortality rate can be explained by the baseline differences between both groups. Previous cancer diagnosis should not be included in the clinical decision process when a patient is having an acute STEMI.

Diagnosis, management and mortality in acute aortic syndrome: results of the Spanish Registry of Acute Aortic Syndrome (RESA-II).

BACKGROUND: Recent advances in the diagnosis and treatment of acute aortic syndrome should improve the outcome of this disease. The Spanish Registry of Acute Aortic Syndrome aimed to assess current results in acute aortic syndrome management in a wide cohort of hospitals in the same geographical area. METHODS: From January 2012 to January 2014, 26 tertiary hospitals included 629 consecutive patients with acute aortic syndrome: 73% men, mean age 64.7±14 years (range 22-92), 443 type A (70.4%) and 186 type B (29.6%). RESULTS: Time elapsed between symptom onset and diagnosis was <12 hours in 70.7% of cases and <24 hours in 84.0% (median 5 hours; 25th-75th percentiles, 2.7-15.5 hours). Computed tomography was the first diagnostic technique in 78% of patients and transthoracic echocardiography in 15%. Surgical treatment was indicated in 78.3% of type A acute aortic syndrome. The interval between diagnosis and surgery was 4.8 hours (quartile 1-3, 2.5-11.4 hours). Among the patients with type B acute aortic syndrome, treatment was medical in 116 cases (62.4%), endovascular in 61 (32.8%) and surgical in nine (4.8%). Type A mortality during hospitalisation was 25.1% in patients treated surgically and 68% in those treated medically. Mortality in type B was 13.8% in those with medical treatment, 18.0% with endovascular therapy and 33.0% with surgical treatment. CONCLUSION: Improvements in the diagnosis and treatment of acute aortic syndrome have not resulted in a significant reduction in hospital mortality. The results of this study reflect more overall and less selected information on acute aortic syndrome management and the need for sustained advances in the therapeutic strategy of acute aortic syndrome.

Survival Advantage of MitraClip® Over Medical Treatment in Patients with Mitral Regurgitation: A Meta-Analysis.

BACKGROUND: The MitraClip® system is a percutaneous treatment for mitral regurgitation (MR) that has shown promising results in patients who are inoperable or at high risk for mitral surgery. Data on the efficacy of the system over optimal medical therapy, above all in patients with functional MR, are scarce. The study aim was to assess the effect of MitraClip on the survival of patients with moderate/severe or severe MR compared to medical therapy, using meta-analytical techniques. METHODS: Independently, reviewers searched electronically for relevant articles based on predefined criteria and end-points. Only articles with a comparison between MitraClip and conservative therapy were included. Standard meta-analysis techniques were used. The primary outcomes were 30-day and one-year mortalities. RESULTS: Five observational reports were included that enrolled a total of 1,271 patients: 720 patients underwent percutaneous mitral valve repair (PMVR) with the MitraClip device, and 551 were managed conservatively. A total of 49 all-cause mortality events was reported at 30 days: 3.05% (22/720) in the PMVR arm, and 4.90% (27/510) in the conservative group, with no significant differences in all-cause mortality (OR 0.64; 95% CI 0.36-1.14). A total of 269 all-cause mortality events at one year was reported: 15.14% (109/720) in the PMVR arm, and 29.04% (160/551) in the conservative group. A significant difference favoring PMVR with the MitraClip system over medical therapy alone was observed (OR 0.44; 95% CI 0.30-0.64, p <0.0001). Neither significance between study heterogeneity (p = 0.18) nor publication bias was detected (p = 0.3). CONCLUSIONS: PMVR with the MitraClip system may be associated with an improvement in one-year survival compared to stand-alone medical management.

A Simple Technique for Aortic Root Dissection and Massive Aortic Regurgitation Repair after Blunt Chest Trauma.

Aortic regurgitation due to valve injury after blunt chest trauma is a rare condition that may be caused by leaflet or commissural rupture, aortic dissection, or a combination of both. The case is presented of a 48-year-old male patient with an aortic dissection and aortic valve commissural detachment and massive aortic regurgitation after a 12-meter vertical free fall and secondary thoracic blunt trauma. The aortic root tear and dissection was repaired with a continuous polypropylene 5/0 suture and subcommissural annuloplasty that restored the aortic valve geometry and resulted in a normally functioning aortic valve.